Case Scenario

What should I do when patients ask me for money? One patient recently requested $3.25 for bus fare to visit her seriously ill sister who lived across town. Sometimes we have bus tokens in the office, but we were out of them that day, so I gave her $2.00 and explained that it was all I had in my pocket. She has a history of substance abuse and depression. Another patient periodically asks me for money; when I ask her what she needs the money for (Food? Cigarettes? Bus fare?), she can't seem to say. I sometimes wonder if she sees me as a parent figure from whom she wants some sort of weekly allowance. I tell her that I don't carry money to the clinic, which is true, but in any case I would feel uncomfortable giving her money—even though I know she is poor.

I once heard a patient in the waiting room say she had no money for medications. The patient sitting next to her reached into her purse and gave her $20. I was touched by this generous gesture. I would like to do the same for my patients when the need is great and I feel certain that it's just a one-time request, but I don't know whether such a gesture would be condescending or otherwise inappropriate. In general, I have good relationships with my patients and know them well.

Commentary

As a rule, physicians should avoid giving money directly to patients. Like most decisions in medical practice, the determination to give a patient money must be weighed carefully, and each case must be evaluated individually. Issues of grave need on the part of a patient and acts of genuine charity must be balanced with concern for potential liability and violation of boundaries in the physician-patient relationship.

Medical literature on the topic of physicians giving monetary gifts to patients is scarce. Conversely, numerous articles have been published on the subject of physicians accepting gifts from patients. Most physicians do, in fact, receive small gifts from their patients from time to time. However, one commentator warns that physicians should not accept gifts of cash, extravagant items, or intimate items from patients and describes how a seemingly innocent and thoughtful deed like gift-giving nonetheless raises multiple ethical concerns.1 Other authors agree that gift-giving from patients to physicians, even with the best of intentions, may represent a threat to the physician-patient relationship, ranging from benign boundary infractions to serious violations.2 Some of these concerns also might apply to the issue of physicians giving money to their patients.

The frequency with which physicians give money to patients is unknown but, based on personal experience and conversations with colleagues, it appears to be an uncommon practice. It seems that physicians rarely give patients money, and those who do tend to keep it a secret. Some physicians are highly altruistic and hesitant to broadcast their kindness. Others are reluctant to have reports of such generosity spread throughout their practices, because they might generate additional requests. A few are simply embarrassed. Most do not feel comfortable giving patients money because they are uncertain about the professional boundaries.

At times, physicians might feel compelled to give money to a patient because, fundamentally, physicians are compassionate and empathetic professionals who care for and about their patients. Further, physicians take seriously the fact that they are entrusted with safeguarding the well-being of their patients. They also have a keen sense of social responsibility and are aware that acts of kindness and charity often benefit not only an individual patient but society as well. Physicians also might be compelled by an ethical imperative to improve the quality of life for their patients and perhaps even to sense their needs.3

Patients request money from their physicians for numerous reasons, but their most commonly cited needs include food, medication, transportation, and housing. It also is common for patients without personal financial need to take advantage of appointments with their physician to solicit donations for such things as charitable organizations, community events, school fundraisers, and orders of Girl Scout cookies.

In spite of laudable and legitimate motives, physicians should be reluctant to give patients money for the following reasons:

There is frequently no guarantee that the money will be spent on a legitimate need, let alone for its stated purpose.

A monetary gift may result in a continued expectation on the part of the recipient that the physician will remain a financial resource in the future. Later, if the same patient's request for more money is not granted, the patient's feelings may be hurt, and he or she may assume that the physician no longer really cares.

Physicians create a quandary when they provide financial funds for some but not all of their patients. At what level should physicians draw the line? It would be difficult to explain to other, perhaps only slightly less needy, patients why a physician gives money to some but not to all patients who ask for financial help.

There may be potential legal consequences to giving money to patients if that money is used in unintended or harmful ways.

Providing money to patients often amounts to a short-term fix and fails to address long-term needs. For example, although it might be more expedient to purchase medicine for patients, in the long run it may be more worthwhile to enroll them in a pharmaceutical company's medication assistance program.

Giving money risks sending hidden messages to some patients (e.g., the presumption that the physician is showing preferential treatment or that he or she must owe the patient a favor).

Most importantly, granting monetary requests from patients generates significant concerns about overstepping the boundaries in the physician-patient relationship.

Strategies for dealing with patients who request money vary. Physicians should have a formal policy that they find comfortable. They can tell people directly but kindly that such a practice is inappropriate, as in: “I'm sorry, but it is my policy not to give money to patients. Unfortunately, I am unable to provide for all of those in financial need, and it is unfair to choose some over others.”

If the physician regularly donates to charitable organizations, he can inform a patient who asks for money that it is his policy to give donations only to the specific groups he already supports. If the physician doesn't bring cash to work, it is fair to tell patients that. However, many patients are aware that most medical practices always have some petty cash on hand, so a physician should be careful not to tell patients he has no cash when, in fact, the patient may have just witnessed the receptionist accepting a cash payment from another patient.

When considering whether to give money to patients, it is important to know them well and know whether they have a genuine need. Certain populations (e.g., persons with a history of substance abuse) may be at increased risk of misusing gifts of money. When a physician decides that a patient's request for money represents a need that might otherwise be unmet and the physician wishes to provide financial assistance, it is almost always preferable to supply the actual item or service needed rather than give money directly to the patient.

Every effort should be made to connect patients in financial need with appropriate local and national organizations, such as food pantries and homeless shelters, as well as organizations that underwrite specific needs. If a physician chooses to give money to a patient, he should always set a limit. There are probably few situations where it is ever appropriate to give someone more than $20.

Giving money to patients may be a generous and thoughtful act on the part of a virtuous physician, but it also could be one that results in serious boundary issues and unforeseen consequences. In most cases, giving patients money is not recommended. We might keep in mind the importance of the hyphen in the term “physician-patient relationship.”4 This humble punctuation mark should serve as a reminder of the distance as well as the connection that exists between physician and patient.

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